Medication Audit Criteria and Guidelines

Clonidine (Catapres®, Kapvay®), Guanfacine (Tenex®, Intuniv®) PEFC Approved: January 2020

Indications ● Attention deficit/hyperactivity disorder ● Symptoms related to opioid withdrawal (clonidine)

Black Box Warning None

Contraindications

Absolute Hypersensitivity to medication prescribed

Relative Pregnancy/nursing mothers

Precautions ● Avoid abrupt withdrawal (rebound hypertension) ● Cerebrovascular disease ● Conduction disturbance ● Chronic liver disease (guanfacine) ● Recent myocardial infarction ● Chronic renal impairment ● Sedation, somnolence ● Severe coronary insufficiency ● Hypotension ● Bradycardia ● AV block ● Syncope or history of syncope

1 Texas Health and Human Services ● hhs.texas.gov Clonidine (Catapres®, Kapvay®), Guanfacine (Tenex®, Intuniv®) January 2020

Adverse Reactions

Side Effects Which Require Medical Attention ● Abdominal pain ● Depression ● Difficulty in breathing ● Extreme dizziness ● Bradyarrhythmia, bradycardia ● Unusual tiredness or severe weakness; drowsiness ● Sodium and water retention or edema (clonidine) ● Raynaud’s phenomenon (clonidine) ● Vivid dreams or nightmares

Pregnancy and Breastfeeding ● See relative contraindications ● Review product-specific labeling. Consider risks/benefits in reviewing medication-specific labeling

Drug Interactions of Major Significance ● Tricyclic antidepressants ● Bupropion (maybe increase potential for seizures) ● Known microsomal enzyme inducer (e.g., phenobarbital, phenytoin) ● CNS depressants ● Drugs that affect sinus node function or AV nodal conduction (digitalis, calcium channel blockers, beta blockers) - clonidine

Special Populations ● Clonidine extended release and guanfacine extended release are approved for children 6 years and older ● Geriatric:  Clonidine - may require a reduced initial dose  Guanfacine – start at low end of dosing range ● Renal impairment:  Clonidine IR – may benefit from lower initial dose, monitor carefully  Clonidine ER – adjust initial dose according to degree of renal impairment, monitor carefully  Guanfacine IR – start at low end of dosing range  Guanfacine ER – dosage adjustment may be necessary in severe impairment ● Hepatic impairment:  Clonidine – no specific recommendations are available

2 Texas Health and Human Services ● hhs.texas.gov Clonidine (Catapres®, Kapvay®), Guanfacine (Tenex®, Intuniv®) January 2020

 Guanfacine – dosage adjustment may be necessary in severe impairment ● Hemodialysis:  Clonidine – supplemental dose following dialysis not necessary  Guanfacine – no dosage supplementation is required following hemodialysis or peritoneal dialysis

Patient Monitoring Parameters ● Blood pressure and heart rate – baseline, then daily for 4 days after initiation or dose increase, quarterly and as clinically indicated ● EKG – For patients with known heart disease, a personal history of syncope, a family history of sudden death at an early age (under age 40 years, especially if both parents had sudden death)

Dosing ● See HHSC Psychiatric Drug Formulary for dosage guidelines for clonidine. ● Exceptions to maximum dosage must be justified as per medication rule.

3 Texas Health and Human Services ● hhs.texas.gov